P - 77629REQUEST FOR ELECTRICAL INSPECTION �'��'��
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� V O�� 9 01 � Minnesota Board of Electricity K� ;�„
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
� ' (651) 642-0800 TTY/MRS 1-800-627-3529 xryvw.e[ectricity.state.mn.us ��;��
Descr -using the back of the white copy if necessary - the work covered by this request:
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GENERAL FEES Outdoor Li hting Standard @$1
SERVICES I POWER SUPPLIES Traffc Signal Standard $5
0 to 400 Ampere @$25 Supplemental Fee $20
401 to 800 Am ere $50 Transformers u to 10 KVA $10
Above 800 Am ere $75 Transformers over 10 KVA $ 20
CIRCUITS I FEEDERS Transformer / Power Su I for Si ns I Outline Li hti� $5
0 to 200 Am ere ONE & TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere $10 Includes the Service and/or Power Supply up to 500 Amperes, A11
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelling Unit @$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional Ins ction Tri s $20
Each S stem Device or Ap aratus $.50 Investigative Fee
ADDITIONS TO THE GENERAL FEES Reins ection Fee $20
MULTIFAMILY DWELLINGS PER UNIT TOTAL FEE SO
3 to t2 Units @$50 Per Unit (minimum total fee is $20) �p ,
Each Additional Unit @$25 *rns aREn roa ins�cTOa use oN�r
OTHER ADDITIONAL FEES y�� ��,. r.�,,�,�a�
Li htin Retrofit $25 pef FiXtuf2 I hereby certify that I inspected the electrical Installation �esc7ibedFii �dh on the dates stated:
Center Pivot I' ation Boom $40 R�'�"'" �a�
Manufactured Home Park Lots $25 ' — —��',z-C`S
Recreational Vehicle Park SRes $5 F'""�'"sPECT'°" _ oA*E
Se arate Bondin Ins ion $20 ~�3 d d'T'
Special inspection $30 pCf HOUf ExaiREO; nanrvoone oA�
Special Inspection $.31 per Mile
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 12 MONTHS
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Date: Rough-in Inspedion Required? �j(es ❑ No Inspection Other Than Rough-In: ❑ Ready Now�Vill Cal�
�� You must cali the inspector when ready! Date Ready:
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at
Job Site SVeet Address ��y
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Township Section Range Fire No. County
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Owner/Occupant Name Please Provide Two (2) Phone Numbers Including Area Code
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Eledrical Utility ElecVipl Utilfty Address
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Contractor / Company Name Contractor License Number Master Electrician or Power Limited Technician
N� ; �- �rL �!� L � ,/� � t ( f� License Number
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Mailing Address (Contractor, Company or Owner Perfortning Installatian)
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AutF�o ' Signature (Cont Performing InstallaUon) Please Provide Two (2) Phone Numbers Including Area Code
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INSTRUCTIONS BACK OF YELLOW OPY BOARD OF ELECTRICITV CnPV ca nrv�n� n,� e. �,....